Manual: Policy Title: Reimbursement Policy Modifiers 80, 81, 82, and AS - Assistant At Surgery Section: Modifiers Subsection: None Date of Origin: 1/1/2000 Policy Number: RPM013 Last Updated: 7/11/2017 Last Reviewed: 8/9/2017 IMPORTANT STATEMENT The purpose of Moda Health Reimbursement Policy is to document payment policy for covered medical and surgical services and supplies. Health care providers (facilities, physicians and other professionals) are expected to exercise independent medical judgment in providing care to members. Reimbursement policy is not intended to impact care decisions or medical practice. Providers are responsible for accurately, completely, and legibly documenting the services performed. The billing office is expected to submit claims for services rendered using valid codes from HIPAA-approved code sets. Claims should be coded appropriately according to industry standard coding guidelines (including but not limited to UB Editor, AMA, CPT, CPT Assistant, HCPCS, DRG guidelines, CMS National Correct Coding Initiative (CCI) Policy Manual, CCI table edits and other CMS guidelines). Benefit determinations will be based on the applicable member contract language. To the extent there are any conflicts between the Moda Health Reimbursement Policy and the member contract language, the member contract language will prevail, to the extent of any inconsistency. Fee determinations will be based on the applicable provider contract language and Moda Health reimbursement policy. To the extent there are any conflicts between Reimbursement Policy and the provider contract language, the provider contract language will prevail. Scope This policy applies to all Commercial medical plans, Medicare Advantage plans, and Oregon Medicaid/EOCCO plans. Reimbursement Guidelines Moda Health makes determinations regarding whether or not assistant at surgery services are reimbursable on a code-by-code basis. When multiple procedure codes are billed for a surgical
session and only some of the codes are eligible for assistant surgeon reimbursement, only the eligible codes will be reimbursed. The assistant surgeon must report the same codes as the surgeon. An exception to this is when the surgeon bills a global code (e.g. maternity care). In that case, the assistant at surgery must bill the specific surgery-only code (e.g. delivery only). Non-physician assistant at surgery services are to be submitted with modifier -AS appended, not modifier -81. Non-physician assistant at surgery services submitted with modifier -81 appended will be reimbursed at the same rate as if submitted with modifier AS appended. The same clinical edits apply to the assistant surgeon as the primary surgeon. Provider Types Eligible for Reimbursement for Assistant at Surgery Services Moda Health considers the following provider types eligible for reimbursement for assistant at surgery services: MD (Medical Doctor) DO (Doctor of Osteopathic Medicine) PA (Physician s Assistant) NP (Nurse Practitioner) RNFA (Registered Nurse First Assistant) Provider Types Not Eligible for Reimbursement for Assistant at Surgery Services The following provider types are not eligible for reimbursement of assistant at surgery service. Moda Health does not credential these provider types, and they are not eligible providers under our member plan language. Certified First Assistant (CFA) Certified Surgical First Assistant (CSFA) Certified Surgical Assistant (CSA) These provider types are also not recognized by Medicare as eligible to bill or be reimbursed for assistant at surgery services. (ASA 5 ) Claims for services of CFAs, CSAs, or CSFAs, will be printed and returned to the billing office. Contracted participating providers and groups are expected to not submit claims for assistant at surgery services performed by CFAs, CSAs, or CSFAs. Members may not be balance-billed for CFA services. Assistant Surgeon Fee Adjustments Procedure codes eligible for assistant at surgery reimbursement: Reported with modifier -80 or -82 appended will be reimbursed at 20% of the established fee. Page 2 of 8
Reported by physician providers with modifier -81 appended will be reimbursed at 20% of the established fee. Reported by a non-physician provider (NPP) with modifier -81 appended will be reimbursed at 10% of the established fee for Commercial and Medicaid/EOCCO, and at 13.6% for Medicare Advantage. Reported with modifier AS appended, will be reimbursed at 10% of the established fee for Commercial and Medicaid/EOCCO, and at 13.6% for Medicare Advantage. Please Note: Other pricing adjustments may also apply before the final allowable amount for each line item is determined. For example, multiple surgery fee reductions, bilateral adjustments, related within global adjustments, co-surgery adjustments, etc. Procedure Codes Eligible for Assistant Surgeon Reimbursement Procedure codes with a CMS assistant surgeon indicator of 2 are eligible for assistant surgeon reimbursement. One assistant surgeon is allowed per procedure code/surgery. A second assistant surgeon will be considered only on the basis of a written appeal when documentation of medical necessity for the second assistant surgeon is submitted. Procedure codes with a CMS assistant surgeon indicator of 0 are not eligible for assistant surgeon reimbursement upon initial adjudication of the claim. However, the claim may be reviewed for reimbursement upon written appeal when documentation has been submitted that supports the medical necessity for the assistant surgeon. Per CMS guidelines, these procedures normally do not require an assistant surgeon, but an assistant surgeon may be medically necessary in some instances. Procedure codes with a CMS assistant surgeon indicator of 1 or 9 are not eligible for assistant surgeon reimbursement. CMS guidelines indicate assistant surgeons cannot be paid on these procedures. No criteria or guidelines for approval upon appeal have been established for procedure codes with an indicator of 1 or 9. In the absence of a CMS assistant at surgery indicator for a particular procedure code, Moda Health may establish an assistant at surgery designation. Reconsiderations of Assistant Surgeon denials Assistant surgeon denials will be reconsidered upon written appeal. Appropriate supporting documentation must be included, such as: Copies of CMS assistant surgeon indicator setting showing an indicator of 0 or 1 for the relevant date of service. Medical necessity for second assistant surgeon or procedure codes with a CMS assistant surgeon indicator of 0. Page 3 of 8
Other relevant coding guidelines. Copy of the operative report and any other relevant medical record documentation. Background Information Modifiers are two-character suffixes (alpha and/or numeric) that are attached to a procedure code. CPT modifiers are defined by the American Medical Association (AMA). HCPCS Level II modifiers are defined by the Centers for Medicare and Medicaid Services (CMS). Like CPT codes, the use of modifiers requires explicit understanding of the purpose of each modifier. Modifiers provide a way to indicate that the service or procedure has been altered by some specific circumstance, but has not been changed in definition or code. Modifiers are intended to communicate specific information about a certain service or procedure that is not already contained in the code definition itself. Some examples are: To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same surgery To indicate that a procedure was performed bilaterally To report multiple procedures performed at the same session by the same provider To report only the professional component or only the technical component of a procedure or service To designate the specific part of the body that the procedure is performed on (e.g. T3 = Left foot, fourth digit) To indicate special ambulance circumstances More than one modifier can be attached to a procedure code when applicable. Not all modifiers can be used with all procedure codes. Modifiers do not ensure reimbursement. Some modifiers increase or decrease reimbursement; others are only informational. Modifiers are not intended to be used to report services that are "similar" or "closely related" to a procedure code. If there is no code or combination of codes or modifier(s) to accurately report the service that was performed, provide written documentation and use the unlisted code closest to the section which resembles the type of service provided to report the service. Codes and Definitions Acronyms Defined Acronym Definition CFA = Certified First Assistant Page 4 of 8
Acronym Definition CMS = Centers for Medicare and Medicaid Services CSA = Certified Surgical Assistant CSFA = Certified Surgical First Assistant NPP = Non-physician Provider Modifier Definitions Modifier 80 Assistant Surgeon: Surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). Modifier 81 Minimum Assistant Surgeon: Minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number. Modifier 82 Assistant Surgeon (when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). Modifier AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery. CMS Assistant Surgeon Indicators are published on the Medicare Physician Fee Schedule Database (MPFSDB). Current values in use are: Payment restriction for assistants at surgery applies to this procedure unless 0 supporting documentation is submitted to establish medical necessity. Statutory payment restriction for assistants at surgery applies to this procedure. 1 Assistant at surgery may not be paid. Payment restriction for assistants at surgery does not apply to this procedure. Assistant 2 at surgery may be paid. 9 Assistant at Surgery concept does not apply. Coding Guidelines Modifier 80 Assistant Surgeon During certain operations, one physician assists another physician in performing a procedure. The physician who assists the operating surgeon would report the same surgical procedure as the operating surgeon. The assistant surgeon generally is present during the entire operation or a substantial portion of the operation to provide assistance to the operating physician. Page 5 of 8
This modifier is not intended for use by non-physicians assisting at surgery (e.g. Nurse Practitioners, Physician Assistants, Registered Nurse First Assistants, etc.). Modifier 81 Minimum Assistant Surgeon At times the operating physician plans to perform a surgical procedure alone. When a minor problem is encountered during the operation that requires the service of an assistant surgeon for a relatively short period of time, this is considered a minimum assistant surgeon. (AMA 2, 3 ) This modifier is not intended for use by non-physicians assisting at surgery (e.g. Nurse Practitioners, Physician Assistants, Registered Nurse First Assistants, etc.). Modifier 82 Assistant Surgeon (when qualified resident surgeon not available) In certain programs or facilities (e.g., in teaching hospitals), the physician who generally acts as the assistant surgeon is a qualified resident surgeon. There may be times when a qualified resident surgeon is not available to assist the operating surgeon, so a physician assists the operating surgeon in this instance. This modifier is not intended for use by non-physicians assisting at surgery (e.g. Nurse Practitioners, Physician Assistants, Registered Nurse First Assistants, etc.). Modifier AS Non-physician Assisting at Surgery Medicare has established the -AS modifier to report Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) services for assistant-at-surgery, non-team member. Therefore, for Medicare reporting purposes and as directed by a commercial third-party payor, to indicate PA, NP, or CNS services for assistant-at-surgery, HCPCS modifier -AS would be appended to the usual procedure number instead of one of the CPT modifiers. Although the intent of the assistant surgeon modifiers [-80, -81, -82] is to report physician services, the results of our survey indicate that many users report the modifiers for a variety of non-physician surgical assistant services. The most common misinterpretation of the assistant surgeon modifiers is to report PA or NP assistant surgical services. Although, from a CPT perspective, this is not the intended use of the assistant surgeon modifiers, some third-party payors consider this an acceptable means of reporting non-physician assistants during surgery. Many have established their own guidelines for reporting assistant surgeon services. Since each third-party payor may establish reporting guidelines that vary from coding guidelines, a clear understanding of CPT coding guidelines, as well as third-party payor reporting guidelines is essential. (AMA 2 ) Medicare Policy: There is no Medicare provider category for RNFAs, no separately billable RNFA services, and no separate reimbursement for RNFA services. Medicare cannot reimburse a surgical assistant's services if the assistant is an unlicensed practitioner and does not qualify to be a Medicare provider. Page 6 of 8
Such services are reimbursed as part of the Diagnostic Related Group (DRG), if inpatient, and part of the Ambulatory Payment Class (APC), if outpatient. The services of RNFAs must not be filed to Medicare Part B as payable services and/or billed to beneficiaries or their secondary insurance. To do so, such providers will be at risk of sanctions for inappropriate billing, which could constitute Medicare fraud. (Noridian 4 ) Assistant at surgery services rendered by a surgical technician, a first surgical assistant, scrub nurse, or any person bearing a title other than physician, PA, NP, CNS or nurse midwife are not payable by Medicare Part B and is not billable to the patient. Billing the services of a non-covered assistant at surgery under the surgeon s performing provider number is an inappropriate application of the incident to guidelines and any services billed in this manner represents an overpayment to the provider and must be refunded to the Program. (ASA 5 ) Cross References A. Robotic Assisted Surgery, Moda Health Reimbursement Policy Manual, RPM006. B. Valid Modifier to Procedure Code Combinations. Moda Health Reimbursement Policy Manual, RPM019. C. Maternity Care. Moda Health Reimbursement Policy Manual, RPM020. D. Modifier 51 - Multiple Procedure Fee Reductions. Moda Health Reimbursement Policy Manual, RPM022. E. Add-on Codes. Moda Health Reimbursement Policy Manual, RPM025. References & Resources 1. American Medical Association. Modifiers Used with Surgical Procedures, CPT Assistant, Fall 1992, page 15. 2. American Medical Association. "A Closer Look at the Use of Surgical Modifiers" CPT Assistant, March 1996: 8. 3. Grider, Deborah J. Coding with Modifiers: A Guide to Correct CPT and HCPCS Level II Modifier Usage. Chicago: AMA Press, 2004. 4. Surgical Assistant Services Revised. Noridian Medicare B News, August 5, 2009. Page 7 of 8
5. Association of Surgical Assistants (ASA). Appropriate Use of Assistant At Surgery Modifiers And Payment Indicators Clarification. The Surgical Assistant. Vol. 19 No. 3, Summer 2013. Page 3. Page 8 of 8